1619988144 NPI number — GRITMAN MEDICAL CENTER INC

Table of content: (NPI 1619988144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619988144 NPI number — GRITMAN MEDICAL CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRITMAN MEDICAL CENTER INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619988144
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOSCOW
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83843-3056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-882-4511
Provider Business Mailing Address Fax Number:
208-883-6580

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-3056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-882-4511
Provider Business Practice Location Address Fax Number:
208-883-6580
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BESST
Authorized Official First Name:
KARA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT/ CEO
Authorized Official Telephone Number:
208-883-2220

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282NC0060X , with the licence number: 39 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002249700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 028771 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010002310 . This is a "REGENCE FACILITY" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 00034 . This is a "BLUE CROSS FACILITY" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 170811 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4103681 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010002311 . This is a "REGENCE PROFEE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002249600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 87734 . This is a "BLUE CROSS PROFEE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 10964 . This is a "WA L & I FACILITY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3305307 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7258908 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 96772 . This is a "WA L&I PROFEE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: XHSP30916 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81536887 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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